Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries
Authors: Steven MacLennan, Nuno Azevedo, Eilidh Duncan, Jennifer Dunsmore, Louise Fullwood, Nicolaas Lumen, Karin Plass, Maria J. Ribal, Monique J. Roobol, Daan Nieboer, Natasha Schouten, Ted A. Skolarus, Emma Jane Smith, James N'Dow, Nicolas Mottet, Alberto Briganti, Isabel Heidegger, Johannes Mischinger Irene Resch, Simon Turba, Robin Zeder, Braninimir Lodeta, Charles Van Praet, Christophe Ghysel, Harm C. Arentsen, Matthias Beysens, Marie-Hélène Vinckier, Alexandre Mottrie, Ruben de Groote, Aleksandar Ivanov Timev, Marincho Ivanov Georgiev, Krassimir Prodanov Yanev, Boris Mladenov, Atanas Slavchev Ivanov, Petar Antonov, Stanislav Valkanov, Igor Tomašković, Tomislav Kulis, Pero Bokarica, Oliver Pavlović, Vinko Krajina, Marijan Situm, Toni Boban, Tomislav Soric, Ivan Vidic, Goran Benko, Zoran Peršec, Tomislav Sović, Roman Zachoval, Jiri Stejskal, Otakar Capoun, Tomáš Pitra, Marek Gojdič, Marek Babjuk, Vojtěch Novák, Michal Grepl, Marek Broul, Jan Novák, Lars Lund, Ulla Nordström Joensen, Michael Borre, Priit Veskimäe, Peep Baum, Toomas Tamm, Rauno Okas, Pyry Jämsä, Kanerva Lahdensuo, Sirkku Siltari, Heikki Seikkula, Christian Palmberg, Taina Isotalo, Gaelle Fiard, Cecile Verrier, Laura Wiedemann, Emilie Lecornet, Priscilla Leon, Clementine Millet, Charles Ponzio, Guillaume Ploussard, Evanguelos Xylinas, Alexandre Ingels, Pierre Bigot, Vincent Le Corre, François Audenet, Sebastian Berg, Rein-Jueri Palisaar, Axel Heidenreich, Felix Seelemeyer, Susanne Krege, Sami-Ramzi Leyh-Bannurah, Jörn H. Witt, Ayanle Abdirahman, Michael C. Truß, Jennifer Kranz, Karagiannis Andreas, Tzortzis Vassileios, Andreou Andreas, Spyridon Paparidis, Nikolaos Ferakis Niall F. Davis, Kevin G. Keane, Adrian Fuentes, Simone Scuderi, Francesco Barletta, Matteo Manfredi, Francesco Porpiglia, Maria Angela Cerruto, Alessandro Antonelli, Francesco Esperto, Marta Rossanese, Domenico Veneziano, Tommaso Castelli, Roberto La Rocca, Marcello Scarcia, Guglielmo Mantica, Silvia Rebuffo, Giorgio Pomara, Nicola Pavan, Tommaso Silvestri, Giulio Francesco Reale, Andrea Polara, Ugo Giovanni Falagario, Giuseppe Carrieri, Giovanni Ferrari, Maurizio Brausi, Luca Orecchia, Filippo Annino, Gražvydas Kazlauskas, Sotir Stavridis, Nenad Radovic, Marko Vukovic, Margaretha Adriana van der Slot, Harman Maxim Bruins, Inge van Oort, Fred Witjes, Henk van der Poel, Christian Beisland, Gunder Lilleåsenm, Stig Müller, Erik S. Haug, Magne Dimmen, Anna K. Czech, Lukasz Nyk, Jaroslaw Jaskulski, Krzysztof Ratajczyk, Nuno Azevedo, Isaac Braga, João Pereira, Rui Lúcio, João Pina, Edgar Miguel Calvo Loureiro Tavares da Silva, Frederico Furriel, Paulo Mota, Miguel Rodrigues, George Daniel Radavoi, Nicolae Crisan, Iulia Andras, Stoica Robert, Ovidiu Bratu, Cristian Surcel, Sergei Kotov, Vigen Malkhasyan, Sergei Petrov, Sergei Reva, Uros Bumbasirevic, Viktor Kováčik, Ivan Perečinský, Ľuboš Rybár, Ján Šulgan, Lukáš Briš, Katarína Jursová, Miroslav Chovan, Tomáš Kička, Milena Taskovska, Rok Kovačič, Andraž Miklavžina, Mario Alvarez-Maestro, Javier Mayor De Castro, Juan Aragón-Chamizo, Raquel Sopeña Sutil, Carmen Garau Perrello, Antoni Vilaseca, Jorge Huguet Perez, Julia Aumatell Ovide, Jacques Planas, Angel Borque-Fernando, Elena Sánchez-Izquierdo, Jose Luis Marenco Jimenez, Guillermo Lendínez-Cano, Ignacio Puche-Sanz, Rodrigo Garcia-Baquero, Mario Domínguez Esteban, Daniel Pérez-Fentes, Patricia Parra Serván, Lotta Renström Koskela, Johan Stranne, Bianca Scholtz, Christian Torbrand, Magnus Wagenius, Henrik Ugge, Joakim Örtegren, Janine Langenauer, Valentin Zumstein, Hans Peter Schmid, Malte Rieken, Karim Saba, Raeto T. Strebel, Ashkan Mortezavi, Cyrill Rentsch, Beat Roth, Daniel Eberli, Oechslin Pascal, Rebecca Auer, Hubert John, George N. Thalmann, Sümer Baltacı, Aydın Mungan, Sinan Sözen, Serhat Cetin, Guven Aslan, Levent Türkeri, Volkan İzol, Çetin Demirdağ, Sami Berk Ozden, Gökhan Toktaş, Şaban Sarikaya, İlker Tinay, Talha Müezzinoğlu, Oguzcan Erbatu, Levent Sagnak, Bülent Akdoğan, Cavit Can, Hayrettin Şahin, Cenk Murat Yazıcı, Serhii Volkov, Olexandr Shulyak, David Douglas, Joshua Hemmant, Omar El-Taji, Imran Ahmad, Sarika Nalagatla, Husay Janebdar, Rajan Veeratterapillay, Bhavan Rai, Samantha Conroy, Marcus Cumberbatch, Sachin Malde
Journal: European Urology (2023)

Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation "Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer" was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available.To assess current ADT use before prostate cancer surgery in Europe.This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres.Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence.We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0-32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0-43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated.EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued.Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.